R 6023 PERMIT R_ 6023
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3'2'28 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
e RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME /Y3'LCl1/l roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESSIo ll�(Z!!� ��`'r� ��� EXISTING ROOF COVERING
PHONE 2,5`1— 8 B S - NUMBER OF EXISTING COVERINGS
CONTRACTO,R, .
.Jc SS.� AJ TO BE REMOVED---I—TO BE RETAINED
NAME
ADDRESS /S.g 2 �1d� ��/' /�, TYPE OF ROOF COVERING
CITY&ZIP ` �"/ C.J L
PHONE �t/U-� d. OS2 r . x'(,512 BUILT-UP ROOF El
LICENSENUMBER 6 U ASPHALT SHINGLESEl
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
C— 3 `7 6Y8�6S WOOD SHINGLES ❑
License Claes Lic.Number- ,
Date Biz —F8 Contractor fess 5;uA,Z OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct•alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter B(commendng with 9ectlon 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt tRerelrom and the heels for the alleged ASPHALT SHINGLES qq Il
exemption.Any violation of Section 7031.5 by any applicant for o permit subjects the applicant to R pn
e civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑CrD
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles.alone12 tILgW�I
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that AUG%
WOOD SHINGLES
such Improvements are not Intended or offered for sale.It,however,the building or Improvement 4
Is sold within one year of completion,the owner-builder will have the burden of proving that he did - OTHER(SPECIFYyl I T Vl uw"e fll
not build or Improve for purpose of sale.). u
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Lew. PROVIDE MFG R. INSTALLATION SPECS.
El am exempt under Sec. ,B S P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE . VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUlldlnrf�7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which thls - �//
permit lave and r �(J 0 seismic
,BI have and will maithe pert Worker's Compensation the workfor Insurance,as requiredtortsu Section 37000)
the Labor Code,for the performance of ins work for which this permit Is Issued.My Workar'e / Total 1 2
Compensetlon Insurance cerrler antl Pqolicy number are:
Carrier 5'tGtii FUA.[Y Policy No. S1S5(6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ iz
(This section need not be completed If the permit Is for one hundred dollars III of less.) L.2 7 '12-- 7
I certify that in the performance of the work for which this permit is Issued,I shell not emoloy U f C
any person In any manner so as to become subject to the Workers'Compensellon Lowe of Cali- r All roofs shall be inspected prior to any roofing material b ing
fornix. - installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
EkeTsaipisnisotlExemption,
should become
subject lo the TO
Compenon provisions Certificate
Carlo,youstfo forthwith Comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked, source regulations.
I certify that I have reed this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Covering b be CI S"C',or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
we)agreeto save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments.costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit,granting of this permit. SIGNAT'E OFA PLICA DATE
APPLICANT DATE
PRF-INSPECTION: PLYWOOD: IN-PROGRE
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
PERMIT R_ 6023
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)777-3'2'28 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
e RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME /Y3'LCl1/l roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESSIo ll�(Z!!� ��`'r� ��� EXISTING ROOF COVERING
PHONE 2,5`1— 8 B S - NUMBER OF EXISTING COVERINGS
CONTRACTO,R, .
.Jc SS.� AJ TO BE REMOVED---I—TO BE RETAINED
NAME
ADDRESS /S.g 2 �1d� ��/' /�, TYPE OF ROOF COVERING
CITY&ZIP ` �"/ C.J L
PHONE �t/U-� d. OS2 r . x'(,512 BUILT-UP ROOF El
LICENSENUMBER 6 U ASPHALT SHINGLESEl
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is In full force and
effect.
C— 3 `7 6Y8�6S WOOD SHINGLES ❑
License Claes Lic.Number- ,
Date Biz —F8 Contractor fess 5;uA,Z OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct•alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF El
for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter B(commendng with 9ectlon 7000)of Division 3 of the
• Business and Professions Code)or that he Is exempt tRerelrom and the heels for the alleged ASPHALT SHINGLES qq Il
exemption.Any violation of Section 7031.5 by any applicant for o permit subjects the applicant to R pn
e civil penalty of not more than five hundred dollars($500).):
❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑CrD
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles.alone12 tILgW�I
alone Code:The Contractor's License Lew does not apply to an owner of property who builds or
Improves thereon,and who does such work himself or through his own employees,provided that AUG%
WOOD SHINGLES
such Improvements are not Intended or offered for sale.It,however,the building or Improvement 4
Is sold within one year of completion,the owner-builder will have the burden of proving that he did - OTHER(SPECIFYyl I T Vl uw"e fll
not build or Improve for purpose of sale.). u
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(e)licensed pursuant to the Contractor's License Lew. PROVIDE MFG R. INSTALLATION SPECS.
El am exempt under Sec. ,B S P.C.for this reason
Owner Dere
WORKER'S COMPENSATION DECLARATION APPLICATION DATE . VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUlldlnrf�7
as provided for by Section 3700 of the Labor Code,for the performance of the work for which thls - �//
permit lave and r �(J 0 seismic
,BI have and will maithe pert Worker's Compensation the workfor Insurance,as requiredtortsu Section 37000)
the Labor Code,for the performance of ins work for which this permit Is Issued.My Workar'e / Total 1 2
Compensetlon Insurance cerrler antl Pqolicy number are:
Carrier 5'tGtii FUA.[Y Policy No. S1S5(6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ iz
(This section need not be completed If the permit Is for one hundred dollars III of less.) L.2 7 '12-- 7
I certify that in the performance of the work for which this permit is Issued,I shell not emoloy U f C
any person In any manner so as to become subject to the Workers'Compensellon Lowe of Cali- r All roofs shall be inspected prior to any roofing material b ing
fornix. - installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
EkeTsaipisnisotlExemption,
should become
subject lo the TO
Compenon provisions Certificate
Carlo,youstfo forthwith Comply Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked, source regulations.
I certify that I have reed this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof Covering b be CI S"C',or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
spection purposes.
we)agreeto save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments.costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit,granting of this permit. SIGNAT'E OFA PLICA DATE
APPLICANT DATE
PRF-INSPECTION: PLYWOOD: IN-PROGRE
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY